Ulcerated Hypertrophic Scar in A 21-Year-Old Female: A Case Report
A B S T R A C T
Hypertrophic scarring (HTS) is a
cutaneous condition characterized by deposits of excessive amount of collagen
that create a raised scar at the site of injury. HTS is a result of impaired
mechanism of wound healing process. We report the case of a 21-years old female
who developed two thick hypertrophic scar bands in both inguinal regions,
secondary to burns resulting from the application of a depilatory cream. One
year after the development of the HTS, a red nodule was noted in the right
inguinal region, arising from an elevated soft border. According to the
patient, this erythematous nodule developed as a result of recurrent pruritus
and intermittent and pain originated from the scar. In the dermoscopic
examination blood vessels of various shapes, including short, long, branched
and interrupted forms, were observed. No other dermoscopic features were noted
to suspect a Squamous Cell Carcinoma, Pyogenic Granuloma or even an Amelanotic
Melanoma. The patient was referred for a surgical excision and the biopsy
results confirmed only the presence of exuberant granulation tissue over the
scar.
Keywords:
Hypertrophic scar; Scar; Ulceration
Introduction
Hypertrophic scars (HTS) are defined as a pathological scar that have
abnormal thickness which raises from a previous wound1. The best clinical
predictor for the development of hypertrophic scars is a prolonged inflammatory
wound healing phase. This result usually corresponds with a wound that has not
epithelialized and continues to exudate for more than 3 weeks1,2. Hypertrophic scarring following
surgical procedures, trauma and especially burns is a significant concern for
patients and a challenging problem for clinicians because it can be painful, pruritic,
erythematous, raised and cosmetically unacceptable. Some of the risk factors
for the development of pathologic scarring have been reported to include darker
skin color, female sex, young age, allergy and bacterial colonization3,4. The differential and exclusive
diagnosis of HTSs is important because various types of malignant tumors
resemble these scars5,6. For
example, malignant dermatofibrosarcoma protuberans (DFSP) tumors have been
mistaken for HTSs7,8.
Gonzalez-Vela, et al.9 reported HTSs
as differential diagnoses of sclerotic neurofibroma. Also, several other type
of lesions can develop over a hypertrophic scar, including both benign and
malignant conditions like Keloids, Epidermal Inclusion Cysts, Pyogenic
Granuloma, Squamous Cell Carcinoma (Marjolin’s ulcer) and Dermatofibroma or
Hypertrophic Nodules6,10.
Case Report
We report the case of a 21-years Caucasian old
female who developed two thick hypertrophic scar bands in both inguinal
regions, secondary to burns resulting from the prolonged application of a
depilatory cream. Even though the patient reports that she regularly and
properly treated the burns caused by the depilatory cream, after two months the
presence of HTS was noted. One year after the development of the HTS, a red
nodus was developed in the right inguinal region, arising from an elevated soft
border (Figure 1). A small haemorrhagic erosion was observed nearby. According
to the patient, this erythematous nodule developed as a result of recurrent
pruritus and intermittent pain originated from the scar. In the dermoscopic
examination blood vessels of various shapes, including short, long, branched
and interrupted forms, were observed (Figure 2). No other dermoscopic
feature was present. The clinical diagnoses of this nodus were considered among
a Pyogenic Granuloma, a Dermatofibroma or an Epidermal Inclusion Cyst. Squamous
Cell Carcinoma and Amelanotic Melanoma were also suspected, although these
lesions are rare and typically develop in HTSs that have been present for many
years. The patient was referred for a surgical excision (Figure 3). The
histopathologic report was: an exuberant granulomatous inflammation, eroded and
ulcerated, with epidermal inclusions in the dermis associated with nonspecific
chronic inflammation. No other significant elements were identified (Figure 4).
Figure 1: Red nodus over a thick hypertrophic scar on
the right inguinal region
Figure 2: Dermoscopic features of the nodus showing
blood vessels of various shapes, including short, long, branched and
interrupted forms
Figure 3: Hypertrophic Scar and the red nodus before surgical intervention
Figure 4: Exuberant granulomatous inflammation, eroded
and ulcerated, with epidermal inclusions in the dermis associated with
nonspecific chronic inflammation
Discussion
In front of a patient with pathological scars, many physicians have difficulty in differentiating HTS firstly from keloids. HTS are usually raised, although rarely elevated more than 4 mm above the skin; red or pink in colour; hard; and pruritic. Additionally, these scars do not extend beyond the general geographic margins of the wound and tend to regress over time11. In contrast, keloids continue to evolve over time and do infiltrate the surrounding tissue. Our patient presented red to purple raised thick bands at both inguinal regions which do not extend the original margin of the burns. Several types of lesions can develop over a hypertrophic scar, including both benign and malignant lesions6. Clinically it is very important to distinguish these lesions and to make the right differential diagnoses. Our patient presented a red nodus arising over an elevated soft border and the main differential diagnoses were Inclusion Epidermal Cist (which generally occurs within or under a scar), Pyogenic Granuloma (appears as small, red friable nodule which bleeds easily) and Dermatofibroma (generally are firm nodules). Based on the clinical appearance, but without the support from dermoscopic findings a suspicion was raised for Squamous Cell Carcinoma and Amelanotic Melanoma. Despite numerous case reports, epidemiologic evidence regarding true rate of skin cancer in scars of any aetiology is sparse12. One eligible cohort Danish study assessed skin cancers specifically on past burn injury sites and found a burn-site-specific SIR of 1.2 (95% confidence interval (CI) = 0.4–2.7) for Squamous Cell Carcinoma (SCC), 0.7 (95% CI = 0.4–1.1) for Basal Cell Carcinoma and 0.3 (95% CI = 0.0–1.2) for Melanoma13. Moreover, these malignancies typically appear many years after burns and scar formation, whereas the patient has only a one-year history. Pathology reported exuberant granulomatous inflammation, eroded and ulcerated with epidermal inclusions in the dermis. Ongoing studies confirm that the possibility that a nodule over an HTS represents simply exuberant granulation tissue is relatively high, especially if there has been ongoing local irritation and mild infection or repeated trauma14,15. The patient reports persistent pain localized at the area of the scar, with pruritus providing the only perceived relief. Additionally, she has experienced ongoing psychological distress due to the aesthetic disfigurement, which has significantly impacted her quality of life, including difficulties in intimate relationship related to the presence of the HTS.
Conclusion
The purpose of presenting this case lies in the
fact, that even the possibility that a nodus over a HTS represent simply
exuberant granulation which often appears red, raised and may bleed easily, it
can be mistaken for more a serious lesion. Clinical, dermoscopic and
histological evaluation is necessary to differentiate it from other benign and
malignant lesions.
References
2. Latoni
DI, McDaniel DC, Tsao H, Tsao SS. Update on the Pathogenesis of Keloid
Formation.